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Four tasks of mourning William J. Worden (MGH) 1.accepting reality of death 2.experiencing pain of emotions 3.adjusting to environment (with missing person) 4.relocating person within one’s life and finding ways to memorize

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Uncomplicated grief and clinical conditions (Cohen et al, 2006) ‘Bereavement’ in DSM-IV –V62.82 Other (additional) conditions that may be a Focus of Clinical Attention Uncomplicated grief resembles Major Depressive Disorder (MDD) But: MDD not diagnosed in first 2 months after death

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Unless person has: –Guilt about things (other than actions taken/not taken at time of death) –Thoughts of death (other than feeling s/he would be better off dead/should have died with deceased) –Preoccupation with worthlessness –Psychomotor retardation –Prolonged/marked functional impairment –Hallucinations (other than of death person)

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Complicated Grief (CG) (Cohen et al., 2006) ‘Traumatic distress’ symptoms (4/8) –Purposelessness about the future –Numbness, detachment or absence of emotional responsiveness –Difficulty believing or acknowledging death –Felling that life is empty/meaningless –Feeling that part of oneself died –Shattered world view –Assuming symptoms of harmful behaviors of the deceased person –Excessive irritability, bitterness or anger related to death Symptoms last at least 6 months Significant functional impairment

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Inventory of Complicated Grief 19 item scale –I think about person so much that it’s hard for me to do the things I normally do –I feel I cannot accept the death of the person who died –I feel myself longing for the person who died –I feel drawn to places and things associated with the person who died –I can’t help feeling angry about his/her death –I feel disbelief over what happened –I feel stunned or dazed over what happened –Ever since he/she died, it is hard for me to trust people –Ever since he/she died, I feel as if I have lost the ability to care about other people or I feel distant from people I care about –I feel lonely a great deal of the time ever since he/she died –... Frequency: 0=never, 1=rarely, 2=sometimes, 3=often, 4=always)

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Extended Grief Inventory (Layne et al., 2001) Suitable for ages items (normal and traumatic grief) Agreement on 5-point Likert scale Three factors –Traumatic grief “I don’t talk about the person who died because it is too painful to think about him/her” –Positive Memory “I enjoy good memories of him/her” –Ongoing Presence “I think that I see or hear him/her, or that I can feel his/her presence nearby”

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Traumatic grief (23 items) “I can’t stop thinking about the person who died when I want to think about other things” “I don’t do positive things that I want or need to do because they remind me of the person who died” “I feel more irritable since he/she died” … Positive memory (3 items) “I feel that, even though the person is gone, he/she is still an important part of my life” “I enjoy thinking about him/her” Ongoing Presence (2 items) “I have pleasant or comforting dreams about the person who died”

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CTG as a new mental health disorder Brown & Goodman (2005) suggest that CTG a new mental health disorder Must –Distinguish from normal grief reactions –Conceptual and empirical distinguish from other established psychiatric syndromes/disorders (e.g. PTSD, major depressive disorder)- these other disorders are also commonly associated with traumatic death

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CTG as new disorder common first-year following death (e.g. Dowdney, 2000) –Internalizing symptoms (depression and anxiety) –Externalizing behavior –Somatic complaints all PTSD symptoms of avoidance in CTG –maybe better explained by dysphoria associated with depression Withdrawn due to anhedonia –maybe actually avoiding situations for fear of exposure to reminders –or going through period of sadness all supposed to underscores the need to consider CTG as new disorder

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Discussion Do you think there is a need for CTG as new mental health disorder?

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Proposed Criteria for Traumatic Grief (Jacobs et al., 2000) Criterion B ( following symptoms marked and persistent) [number?] 1.Frequent efforts to avoid reminders of deceased (e.g. thoughts, feelings, activities, people, places) 2.Purposelessness or feelings of futility about the future 3.Subjective sense of numbness, detachment, or absence of emotional responsiveness 4.Feeling stunned, dazed, or shocked 5.Difficulty acknowledging the death (e.g. disbelief) 6.Feeling that life is empty or meaningless 7.Difficulty imagining a fulfilling life without the deceased 8.Feeling that part of oneself has died 9.Shattered worldview (e.g., lost sense of security, trust, or control) 10.Assumes symptoms or harmful behaviors of, or related to, the deceased person 11.Excessive irritability, bitterness, or anger related to the death

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Prevalence (uncomplicated grief) Over course of lifetime almost everyone (normal grief?) In children and adolescents –40% of college students report death of peer –More than 2 mio. children and adolescents in the US per year (Rheingold et al., 2003)

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Data from the National survey of adolescents (NSA) Normal loss/grief (not traumatic?) N=4,023 adolescents aged 12 to 17 years Prevalence of past-year deaths (48.2%) –36.1% death of family member –20.3% death of close friend –8.1% both family member + friend not associated with mental health problems)

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Data from the National survey of adolescents (NSA) Demographic factors –Females, lower SES, African American increased risk of death of family member –Girls, older, lower SES, minority increased risk of death of friend Mental health problems –Death of family member: not related –Death of close friend: related to depression, PTSD and substance abuse (BUT after controlling for demographics and victimization history only substance abuse)

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Problems/ confusion appears to be some confusion in the literature over whether what’s traumatic –Death/loss itself –Nature of death E.g. violent death –Reactions to loss Symptoms, disorder/illness (e.g., PTSD) Some think any loss in children is traumatic (Silverman, personal communication)

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Developing understanding of death Prior to age 3 years –Sense an absence and miss a familiar person –Unlikely to understand difference between temporary absence Before age 5 –May talk about death, but may still expect person to come back –Most children do not realize that everyone will die By ages 9 or 10 –Understanding death as final, irreversible, and inescapable (e.g. Worden, 1996)

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Discussion Would you expect different grief reactions in young children? Do you think a very young child (not fully understanding death) suffers more or less?

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Developing understanding of death Cultural differences (Schonfeld & Smilansky, 1989) –Israeli children performed higher than Americans on Irreversibility and finality Influence on (traumatic) grief reactions?